Provider Demographics
NPI:1295425734
Name:RUSSELL, PENNY LEE (LDO ABO NCLE)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LDO ABO NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15186 IONA LAKES DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-1871
Mailing Address - Country:US
Mailing Address - Phone:239-340-7071
Mailing Address - Fax:
Practice Address - Street 1:17105 SAN CARLOS BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS BEACH
Practice Address - State:FL
Practice Address - Zip Code:33931-5305
Practice Address - Country:US
Practice Address - Phone:239-340-7071
Practice Address - Fax:239-466-9015
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO7367156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician